AHRQ Patient Safety Network

The Collection > Error Reporting and Analysis

PATIENT SAFETY PRIMERS
Detection of Safety Hazards

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Safety Target

•Device-related Complications (68)

•Diagnostic Errors (98)

•Identification Errors (52)

•Discontinuities, Gaps, and Hand-Off Problems (92)

•Fatigue and Sleep Deprivation (15)

•Medication Safety (443)

•Medical Complications (184)

•Nonsurgical Procedural Complications (33)

•Surgical Complications (200)

•Transfusion Complications (19)

•Psychological and Social Complications (66)

Origin/Sponsor

•Africa (2)

•Asia (23)

•Australia and New Zealand (45)

•Central and South America (3)

•Europe (227)

•North America (1251)

Resource Types

•Audiovisual (20)

•Award (5)

•Book/Report (130)

•Clinical Guideline (1)

•Journal Article (1161)

•Legislation/Regulation (9)

•Meeting/Conference (10)

•Newsletter/Journal (5)

•Newspaper/Magazine Article (129)

•Press Release/Announcement (12)

•Special or Theme Issue (35)

•Tools/Toolkit (16)

•Web Resource (43)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (611)

•Active Errors (199)

•Latent Errors (99)

•Near Miss (62)

Approach to Improving Safety
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Error Reporting and Analysis

•Error Reporting (650)

•Error Analysis (726)

•Patient Safety Indicators (92)

Clinical Areas

•Allied Health Services (4)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (1022)

•Health Care Executives and Administrators (1308)

•Non-Health Care Professionals (544)

•Patients (131)

Setting of Care

•Hospitals (889)

•Psychiatric Facilities (7)

•Residential Facilities (33)

•Ambulatory Care (124)

•Outpatient Surgery (22)

•Patient Transport (16)

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STUDY

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

Lin MY, Hota B, Khan YM, et al; CDC Prevention Epicenter Program. JAMA. 2010;304:2035-2041.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

STUDY

Explaining Michigan: developing an ex post theory of a quality improvement program.

Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Milbank Q. 2011;89:167-205.

BOOK/REPORT

MHA Keystone Center for Patient Safety & Quality 2010 Annual Report.

Lansing, MI: Michigan Health & Hospital Association; October 2010.

STUDY

Toward learning from patient safety reporting systems.

Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-315.

NEWSPAPER/MAGAZINE ARTICLE

Deadly infections: hospitals can lower the risk, but many fail to act.

Consumer Reports. March 2010;75:16-21.

PRESS RELEASE/ANNOUNCEMENT

New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI).

Oakbrook Terrace, IL: Joint Commission; May 17, 2011.

MULTI-USE WEBSITE

Solutions for Patient Safety.

Ohio Business Roundtable. 41 S. High Street, Suite 2240, Columbus, OH, 43215.

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

STUDY

Medication errors during medical emergencies in a large, tertiary care, academic medical center.

Gokhman R, Seybert AL, Phrampus P, Darby J, Kane-Gill SL. Resuscitation. 2012;83:482-487.

STUDY

Preventable morbidity at a mature trauma center.

Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.

SPECIAL OR THEME ISSUE

Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit.

Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.

COMMENTARY

Quality: performance improvement, teamwork, information technology and protocols.

Coleman NE, Pon S. Crit Care Clin. 2013;29:129-151.

COMMENTARY

Patient safety in the context of neonatal intensive care: research and educational opportunities.

Raju TN, Suresh G, Higgins RD. Pediatr Res. 2011;70:109-115.

STUDY

Perceptions of risk to patient safety in the pediatric ICU, a study of American pediatric intensivists.

Bauer P, Hoffmann RG, Bragg D, Scanlon MC. Safety Sci. 2013;53:160-167.

NEWSPAPER/MAGAZINE ARTICLE

Preventing infections: how Portland hospitals compare.

Rojas-Burke J. The Oregonian. May 8, 2010.

STUDY

The interrelationship of isolation precautions and adverse events in an acute care facility.

Spence MR, McQuaid M. Am J Infect Control. 2011;39:154-155.

STUDY

Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit.

Buckley MS, Erstad BL, Kopp BJ, Theodorou AA, Priestley G. Pediatr Crit Care Med. 2007;8:145-152.

STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

STUDY

Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit.

Abstoss KM, Shaw BE, Owens TA, Juno JL, Commiskey EL, Niedner MF. BMJ Qual Saf. 2011;914-922.

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